Report from Puerto Rico

It had been over a month since Hurricane Maria struck when José Lozada, MD,
FACP, ACP Governor for the Puerto Rico chapter and a hematologist/oncologist, spoke
to ACP Hospitalist. But medical practice and everyday life in Puerto Rico were still far from normal.
Dr. Lozada described his own experiences during the hurricane, the ongoing challenges
facing the island, and potential assistance from the mainland in a phone interview
in early November.

Q: What was it like during and immediately after the hurricane?

A: This hurricane officially hit us as a category 4 storm, but with the gusts it was
pretty much category 5, and it was a slow track through the island, so it was over
12 hours. The impressive part was going outside after. The main issue—that
is still giving us trouble—is our very outdated power grid was just completely
obliterated. This thing snapped cement poles like they were matchsticks. The big towers
that carry power transmission cables, a lot of those were bent or knocked down. We
lost telecommunication. Cell service was basically nonexistent. Few people have old-style
phone lines anymore. People either go with cell phones or with cable, and cable companies
need power.

Q: How did the loss of power affect hospitals?

A: The first couple of weeks were very tough. Hospitals were running on diesel plants.
Right now, out of 65 working hospitals on the island, 57 have electricity. The ones
we had at the beginning were all running on diesel plants, and it was hard to get
diesel to keep them running. The first week or two, [there were] 12-hour lines at
gas stations.

Hospitals that were on the grid, they would lose power . . . surgeons having to use
the flashlight on their cell phone because they lost power in the OR. Because of lack
of refrigeration, access to insulin was an early problem, although that's been fixed.
People were having problems just getting to the hospital, because the roads were blocked,
they couldn't contact an ambulance.

In the hospitals at first, we had problems with blood products, because no flights
were coming in for several days. We have backup with the American Red Cross and some
private blood banks that have contracts with some blood banks in Florida, but if there's
no planes coming in. . . . I remember in the onc ward, because of chemotherapy and
other problems, there were like 12 patients with very low platelets and we had none
for several days. We'd joke with the nurses, “Just don't drop them, please.
Don't let them hit their heads, because we'll be in trouble.”

Q: How are things now?

A: Now the patients are pretty much able to get to the hospitals and hospitals are working.
We have 65 working hospitals, which is most of them. But the outpatient care continues
to be a big challenge, particularly for the internists. The main issue is power. Right
now, if you look at the government site, they say we have 33% power generation, but
that's the capacity of generating power. That doesn't mean that 33% of people and
businesses have power. That's much lower. That's under 20%.

My wife is saying, ‘I miss the air-conditioning,’ but I get home, we
light up a gas lantern like you'd use for camping, and then I light up the charcoal
grill and we barbeque every night. That's a minor issue, not having power at home,
compared to not having power at the offices.

Puerto Rico is always a decade or two behind the states in business models of medicine.
Down here, the concept of a full-time hospitalist has never really taken off. Most
internists have solo practices, or maybe one associate, and they do fee-for-service
work or are capitated. Most offices don't have power. It depends on where doctors
have their offices how bad the situation is. If you have an office in an office building,
like I do, [with] its own emergency power plant, between the 40 offices here, we split
the cost of diesel. Maybe a month of diesel for the plant to run on limited hours
is going to be about the same as I pay for electricity. Remember our censuses are
all down, because the patients have no phone, maybe no transportation. Sometimes the
offices have no phone. You don't know how many patients you're going to get. Even
paying what you usually pay [for electricity] is a problem.

But here a lot of doctors buy old houses and turn them into an office, so they are
solo in their structure, so they have to have their own small generator, either diesel-run
or gasoline-run. If you have a diesel generator and you're opening like maybe 8 [am]
to 2 [pm], [you] can spend $100 to $200 a day on diesel. And if you're seeing five
or six patients a day, some are saying, ‘It's not worth it for me to open the
office.’ Maybe they'll open two hours a day, some of them sitting on the sidewalk,
because it's 86, 88 degrees down here. The patients will come before it gets too hot
and get their prescriptions. That's a significant burden, but relatively few [physicians]
have left. Most of them are trying to keep working, keep doing their hospital rounds,
seeing the patients that they can.

Q: Has the shortage of outpatient care put a strain on hospitals?

A: More patients are going to hospitals. So far there are a couple of measures that have
eased that, for example, so far patients can show up to the drugstores with their
pill bottles and even if they have no more refills, the drugstores are refilling them
for 30 days until they can go to their doctor. The drugstores opened up pretty early
even without power. Another thing is because of HHS rules—[and] the Medicare
Advantage plans and most of the private health plans have followed suit—during
this time they are not requiring preauthorizations for medications and X-rays.

Q: What are the prospects for things getting back to normal?

A: That's the tough part, right? A month ago, we had 15% generation, so in a month that's
doubled, but nobody gives us a timetable. The governor set an aggressive timetable,
but the fact that he is asking that of the power authority doesn't mean that they
can deliver. He says, ‘I want 95% of people to have power by Dec. 15.’
There's no firm schedule of when what areas are going to be illuminated. So that's
the biggest challenge—power. It's a big domino effect, because if you don't
have power, most small businesses can't run, so people don't have jobs. If you have
physicians who have two or three employees but [are] seeing five patients a day, you
have nurses and secretaries who are laid off until the power comes back.

Q: What kind of assistance have you gotten from medicine on the mainland?

A: The ACP—Dr. [Jack] Ende and his staff—wrote this amazing letter to the [federal] government. My class of Governors has helped a lot, [as did] the different medical societies.
ACP has 152,000 members, and the show of support down here has been fantastic and
we really appreciate it. A lot of medical volunteers have come down here. But we don't
need the manpower. We have the docs. A lot of our docs use their time off to do volunteer
work, which is fantastic. We have the hospitals, we have the medications. The drug
distributors, the drugstores are working—all of them with power plants. But
until the power issue is solved, returning to normal is impossible.

Q: Is there anything physicians on the mainland can do to help?

A: The main help would be . . . we have a lot of families where part of the family is
here, part of the family is on the mainland. A lot of the people whose parents were
here, as soon as they could, they bought them a ticket and shipped them [to the mainland]
only to find out that most of them don't have Medicare Part B. Most of them get a
Medicare Advantage plan down here, because the copay is lower. The problem with Medicare
Advantage is that it doesn't cross state lines. They are cheaper, but they only cross
state lines for emergencies.

One piece of help is that if patients from here don't have a health plan, have consideration—not
necessarily charity, but whatever [internists] can do to help these patients while
they're up there would be appreciated. They're eventually going to come back when
things normalize. I don't think we're going to have a mass permanent exodus. I think
that's the best thing they can do for us—to keep our people healthy while we
normalize down here.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.